Barnabas Health Care Services, Inc.

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on interview and document review, the facility failed to conduct testing of the emergency preparedness plan at least every two years. This had the potential to affect all patients. During review of the facility emergency preparedness plan, the facility provided evidence of one severe weather tabletop drill completed on 2/25/23. The facility emergency preparedness plan lacked evidence of any other testing since. When interviewed on 3/10/25 at 3:37 p.m., the administrator confirmed a facility emergency preparedness drill or exercise had not been completed since 2/25/23. The facility policy Emergency Preparedness plan dated 2023, identified the facility emergency plan must include testing and drills.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on interview and document review, the facility failed to investigate a complaint related to medication set up for 1 of 2 patients (P3) reviewed who received skilled services from the agency. P2’s plan of care (POC) with a certification period of 2/8/25 to 4/8/25, identified a (SOC) date of 10/17/19. Diagnoses included unspecified systolic (congestive) heart failure (a serious condition that occurs when the left ventricle can’t pump blood efficiently), chronic obstructive pulmonary disease (COPD) (a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), and type 2 diabetes with unspecified complications. P2 required skilled nursing visits (SNV) once every other week to help manage P2’s diabetes, COPD, medications, coordination with medical providers and medication set-up. P2’s VA Medication Reconciliation dated 2/13/25, identified the following: 1/24/25, isosorbide dinitrate (a nitrate that dilates (widens) blood vessels and prevent angina attacks (Chest discomfort or shortness of breath caused when heart muscles receive insufficient oxygen-rich blood) 10 milligram (mg) tablets. Take one tablet by mouth every morning, take one tablet by mouth at noon and take one tablet by mouth before bedtime. 1/4/25, ferrous sulfate 325 mg tablets. Take one tablet by mouth daily for iron supplement. RX expiration date 1/27/25. During a home visit on 3/11/25 at 1:00 p.m., P2’ s medications were reviewed with registered nurse (RN)-A while RN-A set up P2’s medications into a plastic rectangle four-line medicine organizer and two plastic rectangle single line medicine organizers. The POC for the certification period 2/8/25 to 4/8/25 and the medication administration log RN-A referred to included isosorbide dinitrate 10 mg tablets. The directions were to take one tablet by mouth three times a day. RN-A was observed to not set up one isosorbide dinitrate tablet into the medicine organizers. Additionally, P2 had a bottle of ferrous sulfate 325 mg tablets. RN-A stated ferrous sulfate was not on P2’s POC or medication administration log and she would need to contact P2’s provider. Upon review of P2’s VA Medication Reconciliation, RN-A stated the ferrous sulfate order was missed on P2’s POC. During an interview with P2 on 3/11/25 at 2:14 p.m., P2 stated RN-A was a “nice lady” but P2 did have concerns that his medication wasn’t set up correctly. It’s supposed to be a 1-hour visit and sometimes it’s 3 hours. RN-A “just doesn’t seem to get it.” P2 stated he always had to count each pill to make sure it’s the right number before taking. For the last 3 medication set ups, not including 3/11/25, the medication set up had been wrong. It should be eight pills in the morning and nine in the evening (after 3/11/25, 9 pills in the morning and 9 pills in the evening, but sometimes there were 7 pills and/or 12 pills. The prior medication set up, P2’s tamsulosin was put in for twice a day when it was supposed to be once a day. P2 knew it was tamsulosin by color and because it was a capsule. P2 stated he would not be able to distinguish the other medication. P2 stated “you can’t trust” the medication set up. P2 stated he had called the agency office three times with concerns. P2 stated he was told the agency would find another nurse but that had not happened. During an interview on 3/11/25 at 2:39 p.m., the administrator stated P2 had called with concerns but the administrator believed it was more of a “getting along” situation. The administrator didn’t make any official documentation but reassured P2 and encouraged P2 to get to know RN-A. The administrator stated she was unaware RN-A was performing medication errors. During a phone interview on 3/11/25 at 4:01 p.m., the director of nursing (DON) stated patient complaints should be documented and investigated to ensure patient safety. A review RN-A’s employee file did not reflect any documentation related to medication errors and lacked any additional education, counseling or education regarding medication set up. The agency policy Handling of Clients Complaints review 3/2024, identified the agency would identify and continually improve the care and services provided to clients by timely, appropriately and effectively handling of complaints received from clients or client’s representative, and/or family members. Complaints are client issues that can be resolved promptly or within 24 hours. Complaints typically involve minor issues such as poor communication with the staff or lack of courtesy from the staff. The following six steps shall be taken when handling client complaints: Listen to the client. This is the most important step when dealing with an unhappy client. Acknowledge the client’s feelings. Empathy is key when it comes to successfully handling client complaints. Keep in mind that this person is a client, he or she may not feel well or just received an unfortunate diagnosis. Demonstrate to client that his or her feelings are valid. Ask questions. Obtain as much information as possible. Read back documentation to be sure all information is correct. This will best help to figure out how to handle the complaint and avoid any issues that could arise in the future. Explain and take action. Inform the client that his/her complaint is being taken seriously and suggest solutions. Explain that it will be reviewed and discussed among the management. Inform the client that the supervisor or administrator will follow up with them after the complaints have been thoroughly investigated. Provide a time frame as to when the client can expect communication regarding the issue. When the client can expect communication regarding the issue. Conclude. Thank clients for taking the time to report the matter to the Barnabas’ attention. Ensure the client understands that his/her satisfaction is Barnabas number one priority. Document complaints. Formally document any client complaints, whether big or small. It is important to follow the protocol for handling issues internally. Follow-up with the client, be sure to do so in a timely manner.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and document review, the agency failed to ensure medications were reconciled and/or set up as ordered for 4 of 7 clients (P2, P5, P1, P3) whose medications were reviewed during home visits or record review. P3’s plan of care (POC) 3/4/25 to 5/2/25, identified a start of care (SOC) 7/23/21, with diagnoses which included diabetes, kidney disease and malignant neoplasm of the kidney. Services included skilled nurse visits (SNV) every other week for nine weeks for medication setup, assist to manage care, maintain safety and work on goals for health maintenance. P3 was prescribed a number of medications which included Lantus insulin 20 units subcutaneously (SQ) in the morning and 25 units SQ in the evening. Review of P3’s Veterans Administration Health Care Services Medication List for Review Summary dated 3/10/25, identified an order for Lantus insulin 10 units SQ every morning and 15 units every evening, with a start date 2/25/25. P3’s Patient Medication List for certification period 3/4/25 to 5/2/25, listed a number of medications with route, does and frequency, which included Lantus insulin, give 20 units SQ every morning and 25 units SQ every evening with start date 1/4/24. During a home visit on 3/11/25, at 11:00 a.m. P3 stated he administered his insulin SQ, using an insulin pen and his current dose was to take 10 units in the morning and 15 units in the evening. P3 stated he had been taking that dose for a couple weeks. When interviewed on 3/11/25, at 3:30 p.m. registered nurse (RN)-A stated she reviewed all the medications a patient had when a recertification visit was completed. If a patient reported a medication change in between recertification visits, she wrote a physician’s verbal order to cover it and then updated the medication list. RN-A had not caught the change in P3’s insulin dosing and she had just completed his recertification visit. It should have been updated on his most recent POC. RN-A stated it was important to have the correct medications on the POC because that was signed by the primary physician and the agency, as well as the patient, were supposed to follow physician orders. The agency policy Medication Management dated March 2024, identified nursing staff were to evaluate client’s medications, including over the counter medications upon admission. Nurses were to monitor and reassess client’s medications at every visit for skilled clients and as needed. The medication profile would be updated for dose changes, frequency change, direction change, route change, medication addition or deletion, new allergy, physician change, and lab order changes. Nurses were to review and compare the medications listed on the POC to the medication bottles in the home and ask if there had been any physician visits since last nurse visit. If there had been a physician visit and the client related a medication was discontinued, or new medication added, the nurse would contact the physician and obtain the new medication orders. Once orders were received, the nurse would update the POC. The medication profile will be updated for dose changes, frequency change, direction change, route change, medication addition or deletion, new allergy, physician change, lab order changes. The changes will be added to the medications. P1’s plan of care (POC) dated 2/20/25 to 4/20/25, identified a start of care (SOC) 11/3/22. Diagnoses included a history of cerebral infarction (stroke), hypertension and gout. Services included skilled nursing visits (SNV) monthly to monitor co-morbidities, manage and set-up medications for the month and to order medications. P1’s Veteran’s Administration (VA) Health Care Services Medication List for Review Summary dated 2/19/25, identified an order for calcium polycarbophil 625 milligrams (mg) one tablet by mouth two times a day with a start date of 12/5/24. P1’s patient medication list for certification period of 2/20/25 to 4/20/25 listed his calcium polycarbophil order as 625 mg one to two times a day. When interviewed on 3/10/25 at 2:25 p.m., registered nurse (RN)-A and the administrator acknowledged the calcium polycarbophil order discrepancy and stated the order P1’s POC should be as listed on his VA medication list as twice a day and not 1-2 times a day. RN-A stated P1 had been taking the calcium polycarbophil correctly twice a day and she had simply not updated the POC. RN-A and the administrator both confirmed the normal agency procedure was to reach out to a patient’s provider with any order discrepancies on the POC to seek clarification and then update the POC accordingly. RN-A stated she had missed ensuring P1’s orders were accurately listed on his POC P2 P2’s plan of care (POC) with a certification period of 2/8/25 to 4/8/25, identified a (SOC) date of 10/17/19. Diagnoses included unspecified systolic (congestive) heart failure (a serious condition that occurs when the left ventricle can’t pump blood efficiently), chronic obstructive pulmonary disease (COPD) (a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), and type 2 diabetes with unspecified complications. P2 required skilled nursing visits (SNV) once every other week to help manage P2’s diabetes, COPD, medications, coordination with medical providers and medication set-up. P2’s VA Medication Reconciliation dated 2/13/25, identified the following: 1/24/25, isosorbide dinitrate (a nitrate that dilates (widens) blood vessels and prevent angina attacks (Chest discomfort or shortness of breath caused when heart muscles receive insufficient oxygen-rich blood) 10 milligram (mg) tablets. Take one tablet by mouth every morning, take one tablet by mouth at noon and take one tablet by mouth before bedtime. 1/4/25, ferrous sulfate 325 mg tablets. Take one tablet by mouth daily for iron supplement. RX expiration date 1/27/25. During entrance interview on 3/10/25, at 1:45 p.m. the administrator stated nurses were to complete a drug regimen review at start of care, with recertification visits and to ask the patient regarding changes to medications at every skilled nurse visit. During a home visit on 3/11/25 at 1:00 p.m., P2’ s medications were reviewed with registered nurse (RN)-A while RN-A set up P2’s medications into a plastic rectangle four-line medicine organizer and two plastic rectangle single line medicine organizers. The POC for the certification period 2/8/25 to 4/8/25 and the medication administration log RN-A referred to included isosorbide dinitrate 10 mg tablets. Take one tablet by mouth three times a day. RN-A was observed to not set up one isosorbide dinitrate tablet into the medicine organizers. Additionally, P2 had a bottle of ferrous sulfate 325 mg tablets. RN-A stated ferrous sulfate was not on P2’s POC or medication administration log and she would need to contact P2’s provider. Upon review of P2’s VA Medication Reconciliation, RN-A stated the ferrous sulfate order was missed on P2’s POC. During an interview on 3/11/25 at 3:43 p.m., RN-A stated she normally would dispense each medication, one at a time, and follow the medication orders while setting up P2’s medications. “I don’t know why I was distracted but I was and forgot to put the isosorbide dinitrate in.” RN-A stated, regarding P2’s ferrous sulfate physician order, P2’s VA Medication Reconciliation was sent to the agency after P2’s certification was complete, and she did not always know when medication changes occurred. However, RN-A stated she missed the ferrous sulfate order on P2’s 12/12/24 Provider After Visit Summary nor the 3/10/25 VA Medication Reconciliation. P2 had not been receiving ferrous sulfate as ordered. RN-A stated “it’s my error.” P5 P5’s plan of care (POC) with a certification period of 2/8/25 to 4/8/25, identified a start of care (SOC) date of 9/2/20. Diagnoses included hypertension (high blood pressure), polyosteoarthritis (a diagnosis that means five or more of your joints have arthritis at the same time) and hypertensive heart disease without heart failure (a condition caused by high blood pressure over a long time). P2 required skilled nursing visits (SNV) once every other week to help manage P5’s condition, monitor and manage care as well as set up medications and ordering medications. P5’s Interagency Referral Form dated 1/25/25, identified the following: Amlodipine 10 mg tablets. Take 1 tablet by mouth every day; and Aspirin EC (enteric coated) 81 mg tablets. Take 1 tablet by mouth every day. P5’s plan of care (POC) for the certification period 2/8/25 to 4/8/25, identified the following: Amlodipine 5 mg tablet. Take 1 tablet by mouth every day; and Aspirin 81 mg tablet. Take 1 tablet by mouth every day. - During an interview on 3/11/25 at 3:54 p.m., RN-A reviewed P5’s POC. RN-A stated “yes, those are errors.” RN-A stated she was aware any time a client received a new physician order, the POC should be updated. However, RN-A did not update the POC when P5’s orders were received. During a phone interview on 3/11/25 at 4:01 p.m., the director of nursing (DON) stated medication reconciliation was critical to be correct to ensure the safety and health of the patient. The 485 is expected to be updated with changes as soon as the agency was notified.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure medications were administered only as ordered by a physician or allowed practitioner for 1 of 2 patients (P2) observed during a skilled nursing home visit. P2’s plan of care (POC) with a certification period of 2/8/25 to 4/8/25, with a start of care (SOC) date of 10/17/19. Diagnoses included unspecified systolic (congestive) heart failure (a serious condition that occurs when the left ventricle can’t pump blood efficiently), chronic obstructive pulmonary disease (COPD) (a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), and Type 2 diabetes with unspecified complications. P2 required skilled nursing visits (SNV) once every other week to help manage P2’s diabetes, COPD, medications, coordination with medical providers and medication set-up. P2’s VA Medication Reconciliation dated 2/13/25, identified the following: 1/24/25, isosorbide dinitrate (a nitrate that dilates (widens) blood vessels and prevent angina attacks (Chest discomfort or shortness of breath caused when heart muscles receive insufficient oxygen-rich blood) 10 milligram (mg) tablets. Take one tablet by mouth every morning, take one tablet by mouth at noon and take one tablet by mouth before bedtime. 1/4/25, ferrous sulfate 325 mg tablets. Take one tablet by mouth daily for iron supplement. RX expiration date 1/27/25. During a home visit on 3/11/25 at 1:00 p.m., P2’ s medications were reviewed with registered nurse (RN)-A while RN-A set up P2’s medications into a plastic rectangle four-line medicine organizer and two plastic rectangle single line medicine organizers. The POC for the certification period 2/8/25 to 4/8/25 and the medication administration log RN-A referred to included isosorbide dinitrate 10 mg tablets. Take one tablet by mouth three times a day. RN-A was observed to not set up one isosorbide dinitrate tablet into the medicine organizers. Additionally, P2 had a bottle of ferrous sulfate 325 mg tablets. RN-A stated ferrous sulfate was not on P2’s POC or medication administration log and she would need to contact P2’s provider. Upon review of P2’s VA Medication Reconciliation, RN-A stated the ferrous sulfate order was missed on P2’s POC. During an interview on 3/11/25 at 3:43 p.m., RN-A stated she normally would dispense each medication, one at a time, and follow the medication orders while setting up P2’s medications. “I don’t know why I was distracted but I was and forgot to put the isosorbide dinitrate in.” RN-A stated, regarding P2’s ferrous sulfate physician order, P2’s VA Medication Reconciliation was sent to the agency after P2’s certification was complete, and she did not always know when medication changes occurred. However, RN-A stated she missed the ferrous sulfate order on P2’s 12/12/24 Provider After Visit Summary nor the 3/10/25 VA Medication Reconciliation. P2 had not been receiving ferrous sulfate as ordered. RN-A stated “it’s my error.” During a phone interview on 3/11/25 at 4:01 p.m., the director of nursing (DON) stated medication administration was critical to be correct to ensure the safety and health of the patient. The 485 is expected to be updated with changes as soon as the agency is notified. A medication error policy was requested but not received.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interview and document review, the agency failed to ensure client code status was accurately identified on the plan of care for 1 of 7 patients (P5) reviewed for code status. P3’s plan of care (POC) dated 1/3/25 to 3/3/25, identified a start of care (SOC) 7/23/21. Diagnoses included diabetes, kidney disease, and malignant neoplasm of the kidney. Services included skilled nurse visits (SNV) every other week for nine weeks for various assessments, medication management, and education. The advanced directives on the POC identified P3 did not have advanced directives on file at the agency, however, under intent was a note that identified CPR (cardio-pulmonary resuscitation). P3’s POC 3/4/25 to 5/2/25, identified a SOC 7/23/21, with diagnoses which included diabetes, kidney disease and malignant neoplasm of the kidney. Services included SNV every other week for nine weeks for various assessments, medication management, and education. The advanced directives on the POC identified P3 did not have advanced directives on file at the agency, however, under intent was a note that identified CPR. P3’s medical record identified a Barnabas Health Care Services CPR-DNR (cardio-pulmonary resuscitation/Do not attempt resuscitate) form dated 12/17/24. The form identified P3 had chosen a DNR (do not resuscitate). Recommended action directed staff not to call 911 for CPR, but staff could call for urgent needs with active treatment up to the point of CPR. If P3 was in cardio-pulmonary arrest, staff were not to intubate, give ventilatory assistance, chest compressions or defibrillation. During interview on 3/10/25, at 3:51 p.m., registered nurse (RN)-A stated the note, which identified CPR on P3’s POC was in error, and she would see that it was corrected immediately. RN-A stated it was important to have the code status reflected accurately on the patient’s POC. The agency typically had patients who had signed a code status, hung a copy on their refrigerator, and that is where emergency or home care personnel would look in an emergency. When interviewed on 3/10/25, at 4:00 p.m., the administrator stated staff were to ensure the patient’s POC had the correct CPR status as identified on the patient’s code status form. The patient kept a copy of the code status form in their home and the agency kept the form in the medical record. The administrator stated the primary physician signed the patient’s POC and that needed to match with the code status form. The agency policy, Advance Directives, CPR-DNR, reviewed June 2022, identified if a client did not have an Advanced Directive, he/she must identify the level of care to be rendered and sign the Barnabas CPR-DNR form. The form must be submitted to the client’s physician for review and signature. Once a signed copy was received, it would be filed in the client’s chart. The form was valid for one year and must be provided and updated to the client during recertification (annually).”

“Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, — (A) The registered nurse must make an onsite, in person visit every 60 days to assess the quality of care and services provided by the home health aide and to ensure that services meet the patient’s needs; and (B) The home health aide does not need to be present during this visit. (ii) Semi-annually the registered nurse must make an on-site visit to the location where each patient is receiving care in order to observe and assess each home health aide while he or she is performing non-skilled care This Element is not met as evidenced by: Based on interview and document review, the agency failed to ensure a registered nurse made an onsite, in person visit every 60 days for personal care attendant (PCA) supervision for 2 of 2 patients (P8, P9) reviewed for non-skilled agency patients receiving PCA services under the agency’s comprehensive home care license. P8’s plan of care (POC) 11/28/24 to 1/26/25, identified a start of care (SOC) date of 12/9/13. Diagnoses included severe intellectual disabilities and cerebral palsy. Services included a nursing visit every 60 days for recertification, personal care attendant (PCA) supervision and care plan review and update. A PCA was ordered 10. 5 hours daily with flex use. P8’s POC 1/27/25 to 3/27/25, identified a SOC date 12/9/13. Diagnoses included severe intellectual disabilities and cerebral palsy. Services included a nursing visit every 60 days for recertification, PCA supervision and care plan review and update. A PCA was ordered 10. 5 hours daily with flex use. P8’s Service Agreement dated 10/26/16, identified the client or responsible party agreed to registered nurse supervision of PCA every 60 days and PCA services for 10.5 hours per day. P8’s nurse visit notes identified the following nurse visits were conducted: -On 1/13/25, a remote nurse visit was done over telephone for P8’s recertification visit and PCA supervision due to inclement weather and illness in the community. -On 11/18/24, a nurse visit was made to the home for in-person recertification and PCA supervision. -On 9/23/24, a remote nurse visit was done over telephone for P8’s recertification visit and PCA supervision. P9’s POC 11/28/24 to 1/26/25, identified a SOC 1/1/06. Diagnoses included moderate intellectual disabilities, spastic hemiplegia and bipolar disorder. Services included nurse visit every 60 days for recertification, PCA supervision, and care plan review/update. A PCA was ordered 11 hours a day, flex use. P9’s POC 1/27/25 to 3/27/25, identified a SOC 1/1/06. Diagnoses included moderate intellectual disabilities, spastic hemiplegia and bipolar disorder. Services included nurse visit every 60 days for recertification, PCA supervision, and care plan review/update. A PCA was ordered 11 hours a day, flex use. P9’s Service Agreement dated 9/1/20, identified the client or responsible party agreed to registered nurse supervision of PCA every 60 days and PCA services for 10.5 hours per day. P9’s nurse visit notes identified the following nurse visits were conducted: -On 1/13/25, a remote nurse visit was done over telephone for P8’s recertification visit and PCA supervision due to inclement weather and per PCA request as there was so much illness in the community. -On 11/18/24, a nurse visit was made to the home for in-person recertification and PCA supervision. -On 9/23/24, a remote nurse visit was done over telephone for P8’s recertification visit and PCA supervision. During interview on 3/11/25, at 3:30 p.m., registered nurse (RN)-A stated she usually did on-site recertification and PCA supervision for all her patients but P8 and P9 did not want her to visit. The patients and families were worried about getting an infection or sick from staff, so she did the recertification by phone, and the doctor had written an order that it would be ok to do it that way. During interview on 3/11/25, at 3:40 p.m., the administrator stated she thought if they had an order from the doctor, they would not have to go on site every 60 days but could go annually instead. The PCA Qualified Professional Services from the PCA manual identified the agency could conduct the required supervision remotely for a person with chronic health conditions or a severely compromised immune system when the provider determines remote supervision was appropriate. The administrator stated the agency did not have a separate PCA licensure and provided the client’s PCA services under their comprehensive home health care licensure, which did not stipulate the same exception to the regulation. The administrator stated the agency did do on-site PCA supervision every 60 days with all their patients except P8 and P9, as they became upset and refused to allow the nurse to come. The agency policy Nurse Supervision dated February 2025, identified unlicensed staff such as the PCA would be supervised by the supervising RN every 60 days for recertification to the location where the client was receiving care to observe and assess while they are performing care. The PCA must be present during the supervision visit”